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.. <br /> SAN JOAQUIIi COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Change Edit <br /> FACILITY ID N FACILITY NAME K`6 S 605 r p c e r <br /> y.S <br /> X• <br /> RECORD ID A PRIOR DIST 1t PRIOR SWEEPS <br /> i al Hazardous Waste Invest azMat Pipeline Invest <br /> Site Mitigation: <br /> Environmentali ssessment ST/CAP <br /> Other Lead Agency Sitio envy: QCB DTSC EPA L Site ater Quality Site then Type Site <br /> DESIGNATED EMPLOYEE !I <br /> PROGRAM EIEt4ENT N =L=�IIEYrTUS <br /> NUMBER OF UNITS <br /> EPA ID /: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> t of same, acknowledge that all site and/or project specific <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agen <br /> ' sociated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> PHS-EHD hourly charges as <br /> the Masterfile Record information Form. <br /> rel also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE44 <br /> %•Title: ���tn1�(� � ��QT1��� Dater <br /> 'AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property by authorize the release of any and all results, geotechnical data and/or <br /> located at the above site address here <br /> �Sr Aiwironmental/site assessment in <br /> to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon a <br /> it is available and at the same time it is provided to me or my representative. <br /> i <br /> Prior <br /> DEADLINE DAT'ESi Inspection: Current / <br /> SCheck R Recvd By <br /> Fee Amount Amount Paid Dati o! Payment Payment Type: Receipt <br />